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Patient Presentation An 8-month-old white male came to the emergency room with his mother visibly upset. She had been in the grocery store, when a well-meaning person asked her if she knew that her son was very yellow-colored. The mother recognizing this for the first time panicked, grabbed him from the cart and came immediately to the emergency room located a few blocks away. The past medical history revealed a previously full-term, healthy infant who had been gaining weight and developmental milestones appropriately. After his 6-month health supervision visit, she had started giving him sweet potatoes, carrots and squash as part of his diet. The family history and review of systems was negative.

The pertinent physical exam showed a smiling infant with growth parameters in the 50-75% and normal developmental milestones. HEENT showed no scleral icterus or yellowing of the mucous membranes. He was obviously yellow-colored generally with increased coloring around the nose and palms and soles. His abdominal examination was negative along with the rest of the examination. The diagnosis of carotenemia was made. The mother was calmed down and was educated about carotenemia. The infant already had a follow-up appointment with his primary care provider within the following month.

DiscussionCarotenemia is a common problem in infants as carotene containing foods are often the first solid foods for infants. This is a benign problem and families can be reassured. It resolves in weeks to months depending on the diet. Carotenes are not synthesized by humans and are obtained through the diet. Carotenes are ingested as amorphous solids and crystals and breakdown of cellular membranes increases the bioavailability of the carotenes. Breakdown of the walls is often mechanical (e.g. grinding up of the food), but absorption is also affected through pancreatic lipases, thyroid hormone, bile acids, dietary fiber and dietary fat.

Carotene occurs in different forms with the most common being α, β, and γ. β-carotene is converted to Vitamin A but the conversion is so slow that even with large amounts of β-carotene Vitamin A toxicity does not occur. Carotenemia is also seen in anorexia nervosa, diabetes, hypothyroidism, liver disease and kidney disease. Some familial forms have been noted. It has also been described in large scale populations when food shortages changed diets significantly to plant-based diets such as in Europe during World War I and II.

Carotenes are deposited in the stratum corneum of the skin because it is fat-soluble giving the skin a yellow color. It is most easily seen in the nasolabial folds, palms and soles and takes about 2 weeks to equilibrate with the blood level. As they do not have a stratum corneum, the yellow discoloration is not seen in the conjunctiva or mucous membranes making it distinguishable from hyperbilirubinemia. Also patients with carotenemia are well and do not have other symptoms of hyperbilirubinemia. To see differential diagnoses for different types of hyperbilirubinemia, click on the following: Direct Hyperbilirubinemia, Indirect Hyperbilirubinemia in Older Children, or Indirect Hyperbilirubinemia in Neonates.

Learning Point
Most people know that carotenes are found in yellow and orange vegetables and fruits, but they often do not appreciate the green vegetables can contain significant amounts. The underlying yellow color is masked by the presence of chlorophyll within the plants.Common foods that contain carotene include:

Fruit

Apricot

Cantaloupe

Mango

Papaya

Vegetable

Asparagus

Brassica – broccoli, brussel sprouts, kale

Cassava

Carrots

Eggplant

Green beans

Greens – beet, collard, spinach, swiss chard, many other plant leaves

Okra

Peas

Sweet potatoes

Squash including pumpkin

Tamarind

Other

Butter

Egg yolks

Milk

Palm oil

Coloring additives

There are many other foods depending on the region in the world.

Questions for Further Discussion
1. What other foods contain beta-carotene that are indigenous to your location?
2. What else can be included in a differential diagnoses of yellowed skin?

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

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We at PediatricEducation.org want to wish all our patrons a very happy holiday season. Our next case will be published on January 5, 2015. In the meantime, please take a look at the Archives, Curriculum Maps and Differential Diagnoses listed at the top of the page.

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Patient Presentation A 15-year-old female came to clinic for her health supervision visit. During the visit she said that although her periods were regular she had heavy bleeding that was interfering with running and swimming. She said that she would soak a pad and tampon every hour during the first 1-2 days then for the next 1-2 days she would soak a pad and tampon every 2-3 hours. On days 5-6 she would soak a pad or tampon every 6 hours. She said she had some cramping on day 1 of her periods but ibuprofen usually took care of the pain. Her menses lasted 5-6 days and occurred every 28-29 days almost since menarche at almost 12 years of age. She denied sexual activity or any bleeding problems. She said that sometimes she was more tired but attributed it to increased sports activities and staying up late to finish homework. Her exercise program included working out with her teammates during and just before the competitive seasons. She ran and swam for fun otherwise. She denied any eating disorders. The past medical history was non-contributory. The family history was negative for bleeding disorders, cancer or gynecological problems. The review of systems was negative including changes in hair or skin, heat or cold intolerance, epistaxis, easy bruising or bleeding.

The pertinent physical exam showed a well-developed female with a weight at the 10-25%, height at the 75% with a BMI of 16.4. These were consistent with previous measurements and she was appropriately gaining weight. HEENT was negative including normal hair texture, thyroid and teeth. She was Tanner V for breast and pubic hair and her external genital examination showed no clitoromegaly and normal introitus. The diagnosis of heavy menstrual bleeding was made. The physician explained that the most likely reason was still anovulatory cycles, however other possibilities existed such as hypothyroidism or a bleeding problem. She also explained that usually this was treated with hormonal therapy, most often with contraceptive pills, but that there were other options such as an intrauterine device or vaginal contraceptive ring. After more discussion the teen and her mother decided that they wanted to discuss the issue with a gynecologist and do the appropriate evaluation at one time with the gynecologist. A referral was made. The physician did suggest that the teen eat an iron-rich diet or take a general multivitamin with iron in it. She also recommended that the girl use ibuprofen throughout her periods to possibly help decrease the bleeding.

DiscussionHeavy menstrual bleeding is a common problem. The rates depend on the population and underlying cause, but can occur 30% of adolescent females who go to a gynecologist. Average menstrual blood loss is 30-40 ml. Hypermenorrhea or menorrhagia are regular menstrual cycles that last too long (>7 days) or are too heavy (> 80 ml blood loss). Metrorrhagia is irregular menstrual bleeding. Menometrorrhagia is abnormally heavy bleeding that occurs with an irregular timing. Dysfunctional uterine bleeding is a more generic term describing prolonged, excessive or frequent, unpatterned uterine bleeding that is not related to an anatomical uterine abnormality or systemic cause.

Adolescents can have a very difficult time accurately describing their menses but abnormal bleeding is considered pathologic if “…menstrual loss requiring pad or tampon changes every 1-2 h, with anything longer resulting in ‘flooding’ or ‘accidents’….” Problems associated with heavy menstrual bleeding include anemia, fatigue, missed school and difficulties participating in social and sporting activities. For young women with various disabilities it may offer the additional challenge of difficulty with managing menstrual hygiene.

Causes of heavy menstrual bleeding include:

Anovulation – most common cause and is normal in the first 2-3 years after menarche due to the immature hypothalamic-pituitary-ovarian axis

Treatment depends on the acuity and severity. Some patients need to be hospitalized and aggressively managed. In addition iron rich foods are recommended for all adolescents but especially those with heavy menstrual bleeding. Non-steroidal anti-inflammatory medications (600-1200 mg/day) have been shown to improve the bleeding too. For patients with chronic heavy menstrual bleeding hormonal treatment is usually prescribed. Combined contraceptives in the form of pills, patches or contraceptive ring are used. Progesterone only treatment is also a potential option in the form of progestin only pills, levonorgestrel intrauterine devices and implants.

Learning PointThe initial evaluation for menorrhagia depends on the history and physical examination but often includes:

Pregnancy test

Sexually transmitted infection screening for chlamydia and gonorrhea

Complete blood count

Prothrombin time (PT)

Partial thromboplastin time (PTT)

Fibrinogen

von Willebrand Factor panel

Thyroid stimulating hormone

Prolactin

Some clinicians will do iron studies during the initial evaluation. Also additional bleeding disorder studies may be ordered if a disorder is suspected such as ristocetin cofactor activity and Factor VIII. If PCOS is initially suspected then testosterone and dehydroepiandrosterone sulfate should also be considered. Pelvic ultrasound is also an initial consideration depending on the circumstances.

Questions for Further Discussion
1. At what age is normal menarche?
2. At what age should an evaluation for late menarche begin?
3. What are treatment options for menstrual cramps?

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

Systems Based Practice
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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Patient Presentation A 5-year-old male came to clinic with a history of constipation and anal itching. The anal itching had been occurring for over 1 month and was worse at night. He would wake his mother because of the itching and scratching. His mother said he had scratches on his bottom that then became so sore that the patient began to retain his bowel movements because of the irritation and soreness. This had been happening for about 2 weeks. “His cousin had pinworms a few months back, so I tried that pinworm medicine from the store, but it didn’t seem to help,” she noted. The past medical history was non-contributory. The pertinent physical exam showed a small but healthy appearing male with normal vital signs and growth parameter in the 10-25%. His perianal area had multiple excoriations. The diagnosis of presumed pinworm infection and secondary constipation was made. Because the cousin and several other extended family members frequently visited the home for extensive time periods, the patient and all the household and extended family members were treated with mebendazole. Hand hygiene and environmental control measures were discussed with the family. The clinical course 3 months later showed that although he was not reinfected, a female cousin had also developed pinworms. Everyone had been retreated and no one else had developed pinworms since.

DiscussionPinworm infection is a parasitic infection caused by the roundworm, Enterobius vermicularis. A person is directly infected by fecal-oral transmission of eggs or indirectly such as through contaminated clothing or bedding. It is frequently seen in children and can easily pass to family members especially in crowded conditions. People can become easily reinfected. It is endemic worldwide. Incubation period is usually 1-2 months and eggs can survive outside humans for 2-3 weeks. Humans are the only known reservoir.

Adult worms migrate at night from the anus to the perianal skin and vulvar areas causing anal or vulvar itching. The itching can cause sleep problems and scratching can cause secondary bacterial infection. The worms can exist in alternative locations such as the vagina, Bartholin’s glands and the urethra. Other distant sites such as the appendix have also been cited in the literature.

Diagnosis is by direct visualization of the adult worms about 2-3 hours after sleep or by the “scotch-tape test” where upon wakening the patient has clear cellophane tape applied to the perianal skin. The tape is then reviewed under a microscope to identify the adult worms. See To Learn More below for images of pinworms. In many cases pinworms are treated presumptively because of the difficulty of obtaining specimens.

Learning PointTreatment for pinworms is by antihelminthic agents such as mebendazole, albendazole, and pyrantel pamoate. Pyrantel pamoate is available over the counter in the US. Medications are given at diagnosis and 2 weeks later because all the eggs may not have been killed with the first dose. In high risk situations, all household or similar members should be treated concurrently. As reinfection is high, subsequent infections are treated the same way.

Hand-washing is imperative for infection control. Hygiene including daily bathing, frequent clothes changing and laundering along with avoidance of long fingernails or nail biting is helpful.

Items to be laundered should not be shaken to decrease the risk of transmitting eggs into the environment and should be placed directly into a washer. Items should be washed in hot water and dried in a hot dryer to kill any eggs. Underclothes and bedlinens should be changed first thing in the morning to decrease the risk of environmental transmission.

Questions for Further Discussion
1. What is the most common parasite in your location?
2. What is the most common helminth in your location?
3. What causes intense pruritis?

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.

Systems Based Practice
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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The information contained in PediatricEducation.org is not a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances.